Confidential - Financial Statement

Name:______________________________________________

Phone:_____________________________________________

Street Address:______________________________________

City:_______________________________________________

State:______________ Zip Code:_______________________

Assets

Cash on Hand in Banks:_________________________

U.S. Government Securities:______________________

Accounts and Loans Receivable:___________________

Cash Value of Life Insurance:______________________

Value of Businesses Owned:______________________

Other Stocks and Bonds:_________________________

Real Estate:____________________________________

Other:_________________________________________

Total Assets:$__________________________________

Liabilities

Notes Payable:_________________________________

Liens on Real Estate:____________________________

Other Liabilities:________________________________

Total Liabilities:$____________________________

Net Worth (total assets minus total liabilities)

$_________________________________________


Source of Income:

Salary:___________________________________

Dividends and Interest:______________________

Bonus and Commissions:____________________

Real Estate Income:________________________

Other Income:_____________________________

Total Income:$__________________________

It is understood that this information will be held in strict confidence by Florida Business Advisors, its staff and officers. The undersigned certifies that this information is true and correct. 

Signature: ___________________________________

Date: ____________________